Inflammatory Bowel Disease: Combination of Immunobiologics: Report of Three Cases

Background: The simultaneous use of immunobiologicals is a non-standard therapeutic option for cases of refractory inflammatory bowel disease (IBD). The objective of the study is to present three cases of Crohn’s Disease (CD) treated with a combination of immunobiologicals. Methods: Review of medical records of three patients from a hospital linked to the Brazilian Coloproctology Residency program. Results: Case 1: Woman, 57 years old, CD for 15 years complicated with transverse gastro-colon, jejuno-sigmoid and perianal fistulas. She underwent subtotal colectomy with ileosigmoidanastomosis, segmental ileum enterectomy, segmental gastrectomy and perianal fistulotomy. It evolved with pancreatic fistula and enterocutaneous fistulas. Insufficient response to several biologics. Adalimumab and ustekinumab were used together. Objective of the combination: to avoid a new surgery if the patient refuses an ostomy. Outcome: required surgery 6 months after association with definitive terminal ileostomy. Case 2: woman, 38 years old, pancolonic CD, stricture in the sigmoid colon, stricture in the lower rectum and multiple perianal fistulas. Use of vedolizumab and adalimumab combined. Objective of the combination: avoid potentially mutilating surgery. Outcome: required surgery with total proctocolectomy and definitive terminal ileostomy. Currently using ustekinumab. Case 3: man, 50 years old, history of perianal abscess drainage and complicated appendectomy. It was complicated postoperatively with perianal fistulas and enterovesical, enterocolic and enterocutaneous fistulas. Lately diagnosed as CD, he was then treated with infliximab (IFX) and underwent further surgery to correct the various fistulas. Even so, he developed abscesses and enterocutaneous fistulas in the lumbar region requiring surgical drainage. He had an anaphylactic reaction to IFX. Adalimumab was then combined with ustekinumab. Objective of the combination: avoid new surgery with intestinal resection. Outcome: excellent response with closure of the fistulas without the need for surgery. Conclusions: The combination of immunobiologicals is an exceptional approach, not originally considered in the main studies of these medicines. This strategy has been indicated for critically ill patients to prevent recurrent surgeries or for those who refuse surgery. It is also considered in patients with disabling extraintestinal manifestations and in cases where perianal disease is associated with luminal disease for the same reasons as extraintestinal manifestations.